title: Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms.
abstract: BACKGROUND
  A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique.
  
  
  METHODS
  A 3D image-based anatomic orientation, clipping field-focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10-15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field.
  
  
  RESULTS
  The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches.
  
  
  CONCLUSIONS
  The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.
authors.affiliation: Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland, ext-ahmed.elsharkawy@hus.fi.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Elsharkawy
authors.forename: Mika
authors.initials: M
authors.lastname: Niemelä
authors.forename: Martin
authors.initials: M
authors.lastname: Lehečka
authors.forename: Hanna
authors.initials: H
authors.lastname: Lehto
authors.forename: Behnam Rezai
authors.initials: BR
authors.lastname: Jahromi
authors.forename: Felix
authors.initials: F
authors.lastname: Goehre
authors.forename: Riku
authors.initials: R
authors.lastname: Kivisaari
authors.forename: Juha
authors.initials: J
authors.lastname: Hernesniemi
mesh_terms: D002550:Cerebral Veins / Q000473:pathology / Q000601:surgery*; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods; D002532:Intracranial Aneurysm / Q000473:pathology / Q000601:surgery*; D008866:Microsurgery / Q000379:methods; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods; D013525:Surgical Instruments; D016896:Treatment Outcome